Clinical Tutoring

Clinical Tutoring

One of the most intense forms of small group teaching is the tutoring of students in clinical practice. This is conducted in very small groups or, quite often, on a one-to-one basis. It is a central part of teaching in medicine, dentistry and other health sciences. The particular forms of clinical tutoring vary, but the principal elements are common: students engage in practical activities with live 'subjects' under the watchful eyes of experienced practitioners. They are 'learning by doing', in a setting where the safety of the patients - and students - is protected. In these situations, clinical tutors (also referred to as clinicians or clinical supervisors), usually have considerable experience in their professions, but may be new to teaching. Clinical teaching is sometimes a part of programs in fields outside the health sciences, such as social work or law. In these fields, students work with clients rather than patients.

Because of the small numbers of students involved, this form of teaching and learning allows a good deal of room for individual approaches, but there are some basic principles which need to be observed. The main challenge is to provide students with the opportunity to learn through observation and personal experience while protecting the welfare and dignity of the patient at all times. The tutor must always maintain a double focus, being alert to the situation and feelings of the patient/client while monitoring closely the learner's responses and thought processes.

A common pattern in clinical teaching is to start with the students as observers, with the clinician demonstrating and explaining a procedure. At an appropriate stage, the students are involved in the conduct of the procedure, often starting with the simpler aspects. This means that the role of the clinical tutor shifts as the learner takes on increasing responsibility - eventually for conduct of the entire activity. In the demonstration stage, the important elements are clear and systematic explanation of what is being done and why, and probing of the students' understanding. As student responsibility increases, the clinical teacher's role should shift to watchful observer, occasional assistant and colleague.

The importance of explaining why things are done in a certain way cannot be over-emphasised. In all areas of learning, if students are given a series of procedures to follow without understanding the reasons for them, they are likely to resort to rote learning of what seem to be arbitrary and unconnected details. If they grasp the rationale or logic of the procedures, they will incorporate them into the conceptual frameworks they bring to the activity.

Probing of students' understanding entails skilful and focused questioning and encouragement of the students' own questions. It is likely that there will not be sufficient opportunity for this to occur during the clinical consultation, so it is essential to provide the opportunity for a thorough de-briefing after the conclusion of the treatment and/or session. Lack of timely and relevant 'follow-up' of this kind is often identified by students and clinical teachers as one of the main problems with this form of teaching.

Key principles of 'learning by doing'

'Learning by doing' is often known as 'experiential learning'. It is essential that students in professional areas such as medicine, social work and law have the chance to practise under supervision before they are ready for independent professional practice. But, in order for them to benefit fully, the learning situations must be close to the actual conditions of professional practice, preparing them for a time when there will be no expert standing by to direct or rescue them.

1. A chance to inquire

A guiding principle of this kind of teaching is that the student must be allowed to learn as much as possible from his/her own experience. The tutor must be slow to intervene, unless patient welfare is threatened. When a student is struggling with what seem to the tutor to be elementary matters, it can be quite difficult not to give the solution. In other areas of teaching, it is often not a good idea to 'hold back' straightforward information from students, as discussion can then become a game of working out what's in the tutor's mind. In clinical teaching, it may be an appropriate part of the process, allowing students (for a while) to struggle with the challenge and pressures of unexpected situations similar to those they will encounter frequently in their professional lives. Judgement is the key. The tutor must be able to determine when further struggle is unprofitable - the student may not know enough or may have reached an emotional state which prevents her/him from thinking clearly. Tact is then required in dealing with the situation in a way which does not humiliate the student and destroy self-confidence. Students are likely to be particularly nervous in clinical contexts and most will need reassurance and support, particularly at first. It can also be embarrassing for the patient and create insecurity if tutor and student are seen to disagree.

2. Assessing preparedness

Another fundamental principle of this form of teaching is that a student must be sufficiently prepared to cope with and benefit from the 'practice'. Curricula in clinical subjects are designed to ensure systematic development, but the tutor has an important part to play in assessing preparedness for particular tasks. This is most effectively achieved through straightforward questioning of students, but will only be successful if students feel free to be quite honest about their knowledge and skill levels and do not try to cover up uncertainty or ignorance. As in all areas of tutoring and demonstrating, establishing trust and rapport is an essential first step. Direct acknowledgment that students are not expected to know everything at the start is helpful. They should be treated and judged as developing professionals; the fact that they have much to learn is a given. Even if they reveal alarming ignorance in certain areas, recrimination is not likely to be productive. Constructive advice about how to acquaint themselves with these areas is much more useful.

3. Contextualising experience

A final principle of experiential learning is that the experience should be placed in a context which allows the student to integrate what has been learned into a broader conceptual framework, to generalise from the specific and to relate this experience to others. This is where the tutor is a valuable and essential guide. In Clinical teaching (1995), Ladyshewsky suggests that experiential learning involves a four-stage cycle of:

1. experience (student watches an expert performing a specific task, then performs the task);
2. debriefing (student discusses his/her own performance with tutor and evaluates it);
3. explanation (the task and its difficulties are discussed within a broader context of theory, and the student is directed to relevant literature);
4. application (student again performs the task with the expectation that performance will be at a higher level).

   The cycle is flexible. It may be appropriate at times to start with the explanation stage, at least in the broad sense of offering an early overview, which can then be revisited and amplified after the clinical experience. It may also be necessary to give some basic instruction relating to procedures and use of equipment before the student begins. But all four stages should be experienced at some point for learning to be thorough.

   In this schema, the tutor's roles are clear. He/she is:

   • a demonstrator of expert practice;
   • a commentator on this practice;
   • a model of professional behaviour in dealing with patients/clients;
   • a monitor of student performance;
   • a protector of patient/client and student welfare;
   • a questioner, using probing questions to assist students to evaluate their own performances;
   • a critic, pointing to problems which students miss or underestimate;
   • a supporter, giving encouragement and reassurance;
   • a guide and expert, directing students to relevant theory, explaining theoretical difficulties and helping students to make connections; and
   • an assessor of the level of student competence.

   The overarching aim of the clinical tutor is to assist students to become independent, critically reflective practitioners.

   Relationship with the patient/client

   There are obviously major ethical issues involved in situations where students are working directly with patients or clients. The welfare of the patient/client must be the over-riding consideration in all circumstances. Informed consent is an absolute requirement. Departments involved in clinical teaching have established procedures for informing 'subjects' and obtaining consent. This may not be the tutor's responsibility; however, it is important that tutors are familiar with the procedures and check that they have been followed. If there has been any breakdown in the system, the tutor must follow this up with the appropriate staff member. If the subject of a procedure changes his or her mind about allowing the student to conduct it, this decision must be accepted immediately.

   When first meeting patients with a student or group of students, use their names, introduce yourself and the students, and explain how you are going to proceed. Ask if they have any questions. Impress on students the need to treat these people with courtesy and respect, and to keep them informed. This instruction will carry little weight unless this behaviour is modelled to students at all times. Some of the most important education which takes place in clinical contexts is learning about the interpersonal side of professional-patient relationships. Clinical tutors have a role in helping students to develop their skills in patient management and will often be asked to assess their competence in this area.

   Assessment in clinical teaching

   This is sometimes a contentious area, and a source of student discontent. In comparison with other forms of assessment in universities, it is perceived by some as 'subjective', plagued by problems of validity and reliability. But assessment of professional competency is crucial if graduates are to offer safe and effective care to the public, and in recent years much progress has been made in clarifying procedures and criteria for this form of assessment.

   Clinical tutors can play an important role in discussing with students the objectives for the clinical sections of the course, the behavioural outcomes associated with these objectives, and the detailed criteria by which performance will be judged. Make sure you are thoroughly familiar with these matters before you start teaching and discuss them early.

   Assessment should reflect the feedback provided to students throughout the clinical sessions. There should be no nasty surprises at the end. If you are required to give a cumulative assessment, it is vital to keep records and to enter observations immediately. You should ensure that the performance of each student is judged on an adequate number of observations. Grades or marks should be justified by comments and explained to students, and they should have an opportunity to discuss concerns with you.

   The dominant consideration with the training and assessment of clinical competence must always be the welfare of the community in which graduates will practice. Clinical assessors have a responsibility to keep constantly in mind the eventual objective of judging the individual student's fitness for practice as an independent professional. Along this path, students should be assessed as appropriate to their development stage.

   Aims and objectives Two common problems in clinical tutoring -and how to avoid them The mix of clinical tutors results in students receiving different - and sometimes conflicting - opinions. Suggestion: Try to turn this situation to advantage, using it to illustrate that professional practice is seldom a matter of applying straightforward and agreed formulae, but is characterised by difference, debate, uncertainty, even conflict. Warn students early that they are likely to be exposed to different views and approaches and suggest that thinking their way through these is an important part of learning and professional development. If, however, the conflict is unproductively confusing or if it involves fundamental principles, this will need to be discussed and clarified with the other teacher(s) involved, and strategies for presenting the disagreement to students determined. There is inadequate 'follow through' from clinical sessions Suggestion: There is no satisfactory alternative to simply making time for a proper debriefing. Even a period of a few minutes spent directly after the session, while the experience is fresh, is invaluable and likely to save a lot of time - yours and the students'- in the long run. Directing students to relevant literature, in a detailed and focused way, is an efficient procedure; so too is the preparation of brief, well-structured handouts giving an overview, summary or questions for further exploration. These methods should be seen as complementary to discussion. To prevent debriefings from becoming ad hoc and unfocused, you should prepare a mental checklist of the performance characteristics that you observed. In a clinic in the health sciences, for instance, you will probably be considering accuracy of diagnosis, appropriateness of treatment plan, successful completion of any procedures, and overall skills in patient management. Take students systematically through the key areas, pointing out and rewarding strengths, as well as identifying areas of weakness and what can be done to improve them. The debriefing is also an opportunity to hear from the students about their experiences of the session and to address any problems or concerns they might have.

   Next chapter: Chapter 7: Assessment, feedback and support

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